COMMENTARY
Mark Croucha
a MD, Public Health Officer, Staff Physician, Kudjip Nazarene Hospital, In His Image International, Papua New Guinea
A seeming contradiction exists between the approach to health as a fundamental human right or as the natural consequence of human responsibility. This paper investigates a Christian approach to health attempting to reconcile these disparate views. The Biblical basis of human responsibility for health is considered as well as the greater forces affecting the health choices of individuals and communities. Ultimately, a combined approach or "working order" toward the fundamental right to health based on human responsibility is attempted.
Key Words: personal agency, human rights, health, responsibility
Nothing is more easily thrown out of working order than the balance between different spheres of thought.
Henry Drummond1
A young woman presents to a faith-based organization’s (FBO) maternal health clinic in a low-middle income nation for family planning services. The FBO does not provide hormonal-based methods of contraception but instead instructs its patients to use fertility awareness methods. In her society, this young woman’s ability to dictate when she participates in sexual intercourse (and perhaps even with whom) is almost entirely out of her control. Three months later she presents to the same clinic, the only one accessible to her, because she is 7 weeks pregnant. The clinic initiates antenatal care for her. Two weeks later she returns extremely ill with an infected and perforated uterus after a failed attempt at a “bush” abortion and subsequently dies.
An apparent conflict exists between the principles of individual human responsibility and certain aspects of health as a human right. Health is defined by the World Health Organization (WHO) not just as the absence of disease but a more robust condition of “complete physical, emotional, and social well-being”2. In fact, the expansive definition of health and the inclusion of “the highest attainable standard of health” as a fundamental right in the constitution of the WHO is a powerful force motivating current efforts in safeguarding the health of individuals in a globalized world. According to the WHO fact sheet on human rights and health, states are obligated to secure access to health care and to provide reasonable conditions affecting the determinants of health for their citizenry.3
A conflict arises when the determinants of health are partially or wholly within the decision-making powers of the citizen(s) themselves, i.e., in our example, the choice to engage in unsafe sexual practices or to access inappropriate health services. One could argue that personal responsibility in making unhealthy choices negates the need to provide for a right to health, since a person has taken action to jeopardize their own health. Biblical principles of stewardship of the body might be used to support this stance.4 Looking into the United Nations Universal Declaration of Human Rights, one might argue against providing health as a human right because safeguarding one person’s right to “medical care and necessary social services” (Article 25) might infringe another’s not to be “deprived of his property” (Article 17).5 Perhaps because of this conflict, the WHO fact sheet suggests that states focus on access to health care and the conditions that are (supposedly) within government control, like gender equality and reasonable infrastructure, rather than on guaranteeing health as a human right.3 Yet could this right to health care access foster an entitlement mentality and a shirking of individual behaviors, leading to the health system or tax-payers cleaning up after the unhealthy choices of the sick?
For the Christian, is there a conflict between a Biblical approach to responsible stewardship of the body and the right to health? These different spheres of thought interact frequently in global health, where FBOs provide a substantial amount of services in many low-middle income countries and where many cultures appreciate the influence of faith on health. If the balance of Biblical stewardship of the body and health as a human right is not elucidated, Christians may find themselves struggling to provide care that is both Christ-like and socially just.
To strike this balance appropriately, the Christian global health worker should recognize the danger in attributing principles like personal responsibility to Biblical virtues. They must also acknowledge the complex array of forces shaping individuals’ behaviors. While personal health choices ought to be considered when crafting policy based on health as a human right, the limited agency available to many of the world’s destitute and sick should temper arguments that entitlement will naturally follow provision of health as a human right. Christians have a unique role to play in addressing the spiritual and cultural factors that influence the complex forces which shape an individual’s health.
For the Christian, social and political forces often intersect with Biblical principles. Most pertinent to the discussion of health as a human right would be a political view that social ills like poverty or ill health represent a failing of personal responsibility. Is this a Biblical principle? As pointed out, some would argue that the scriptural mandate to steward the body in a way that honors God’s instructions is evidence that responsibility dictates personal health. For behaviors with clearly elucidated links to poor health, this makes sense. Those who drink to excess or use tobacco products and subsequently develop liver disease or emphysema may, rightly, blame their own behaviors.
However, taking this concept of personal responsibility further, a state may conclude that the health of its citizenry is not something that can or should be guaranteed as a right. People should exercise temperance, moderation, and civility in order to safeguard their own health. Governments might provide access to care or work to improve conditions affecting health but may emphasize conditions felt to be beyond an individual’s choices. Christian authors have suggested that this represents a union of “moral discipline and civil government” and creates a system in which the “focus shifts from rights to responsibilities.”6 Such a shift to responsibility suggests that when considering how to provide health services and to whom, the Christian worker should ask, “Who is to blame for this malady?”
Looking into scripture, though, when Christ is asked by his disciples regarding a man being born blind, he ignores the issue of blame. Indeed, he says that assigning it only distracts from the true issue—“that the works of God should be revealed.”7 It seems that Jesus considers demonstrating God’s heart to restore an individual as more important than considering how their brokenness occurred. Perhaps the better question to ask is not if personal responsibility absolves the Christian from promoting health as a human right but, instead, what role the Christian plays in bringing the tangible expression of God’s healing into the lives of those they encounter. The principle of personal responsibility may not be the primary virtue evident in Biblical scripture.
Human responsibility is not exercised in a vacuum. The choices that individuals make occur within a complex system of competing forces. These forces often drive individuals or entire communities into unhealthy living. As Bryant Myers explains in discussing the underlying issues creating poverty, these include the physical, social, mental, and spiritual spheres. Such issues applied to poverty involve entire “disempowering systems.”8 Yet such systems not only influence choices that individuals make regarding their social or economic situation, but their health as well.
The various forces that affect a person’s responsibility may make healthy choices impossible. The Christian who attributes all ill health to individual human responsibility must ignore, or at least seriously underestimate, the effects of a world groaning for redemption.9 As medical anthropologist Simon Cohn points out, if one fails to recognize the complex forces acting upon an unhealthy person’s choices, “the social, affective, material, and interrelational features of human activity are effectively eliminated, as behaviour becomes viewed as an outcome of the individual.”10 If behaviors are solely an outcome of personal responsibility, then health as a human right is a violation of natural consequences.
Such an argument lends itself to those who endorse policies directed at improving health behaviors, like health education activities, but abandon the greater battle against larger social structures at play. This might be expedient for stretched governance bodies, often balancing thin budgets, who can level accusations at individual or community choices and wash their hands of responsibilities to provide health care. However, the Christian should exercise caution in following suit. When assessing whether a person’s choices are a genuine reflection of their level of responsibility, one ought to consider broader factors that could limit that person’s agency.
In the opening narrative, a young woman succumbs to the catastrophic consequences of a tragic personal decision to pursue an unsafe abortion. If human responsibility is to blame for her ill health and subsequent death, whose responsibility has fallen short? The young woman who did not “control” her sexual activity or chose to pursue a dangerous medical procedure? The society around her that allows men to enforce their sexual appetites with little concern for their partners? The FBO for not providing a more effective method of contraception in that environment? If the young woman’s claims to health depend on human responsibility rather than as a basic right, should her death be viewed as a just end to poor choices?
There is nothing wrong with underlining personal agency, but there is something unfair about using personal responsibility as a basis for assigning blame while simultaneously denying those who are being blamed the opportunity to exert agency in their lives.11
Paul Farmer
The Christian health worker must recognize a litany of areas in which individual human responsibility yields to the greater and complex forces around it. Even the capacity for exercising individual choice may yield to beliefs that affect “levels of perceived control.”8 For example, an illiterate woman whose husband tells her that their holy book prescribes sex on demand would foster a deep belief that forces her to give up any attempt at personal agency in such interactions—like suggesting the use of a condom.
While limited agency does not grant an individual limitless excuse, it should powerfully color the dialogue of health as a human right, especially for Christians working in such environments. The tragedy would be amplified if the individual operating under limited agency shoulders blame for their conditions, which then excludes them from receiving appropriate health services. For example, a mission hospital refuses care for complications to those who have undergone illegal abortions. In this sense, the health of the individual is best safe-guarded by viewing it as a right. For those who instead choose to emphasize personal responsibility, perhaps the greater responsibility is not on the sick individual but on the Christian to reach out to the afflicted, without blame, and ameliorate their suffering - as in the Biblical story of the Good Samaritan.12 “Rights and responsibilities… are two sides of the same coin. If you are sick, because I see in you the image of God it is my duty to care for you.”13 The reconciliation of human responsibility with limited agency enables the Christian to find a working balance that sees health as a human right which, like all others in a fallen world, can only be realized to a limited extent.
These two disparate spheres of thought, health as a human right and the reality of human responsibility, must find a “working order” in the Christian who would provide care to the destitute and sick of the world. Individuals powerfully shape their health within the forces around them. Yet a health worker attempting to bring Christ-like care to the suffering may, like Nouwen, ask, “Why do I spend so many hours talking about the individual pains of people, while I leave the society that creates these pains unchanged?”14 To acknowledge external forces affecting health behaviors enables a physician to not only treat the suffering of the patient they encounter, but to examine the structures around that person. Critically, this allows the Christian to separate “responsibility” from “blame.” This must happen if the spheres are to be reconciled. Individuals and entire communities bear responsibility for adverse health. However, blame does not inseparably follow responsibility because of greater realities that influence health. An active enemy, social disempowerment, and spiritual vacuity, they all bear varying levels of blame for much of the misery that threatens to overwhelm our world.15 When human choices are understood in light of the complex forces that shape them, the Christian is free to emphasize health as a fundamental right that requires an environment promoting personal agency.
If willing to address fundamental rights issues, Christians can guide a discussion of fostering favorable environments to a greater degree than strictly secular actors can. Too much emphasis on “structural violence” or other powers disrupting personal agency ignores an arena that much of the world considers important, namely the spiritual or religious.11 An appreciation of fundamental rights can go only as deep as the fundamental world-views of those involved. The Christian shares a basic belief structure in the supernatural with much of the world. From there, deeper forces that constrain personal agency can be investigated in light of the Gospel—a Gospel which offers the redemption of entire societies.16 Such changed societies can expect to see the fundamental right of health realized in communities that value persons, and their ability to make choices, in the image of God.